Frederick County Public Schools Enrollment or Change Form

Frederick County Public Schools Enrollment or Change Form

1. SUBSCRIBER INFORMATION Employee ID

Employee Name (Last)

(First)

(MI)

Spouse with FCPS

Yes

No

Street Address

Spouse Name (Last)

(First)

(MI) Spouse ID City

State

Zip

Sex

M

F

Marital Status Single

Married

Date of Birth Divorced

Telephone Numbers Home Work

Retiree

Yes

No

2. HEALTH CARE OPTIONS

Medical Plan BlueChoice Advantage

Dental Plans (choose one) Dental Standard Dental Buy-up

Individual

Employee + 1

Family

Waive

3. ENROLLMENT INFORMATION Please complete this information for yourself and all dependents covered by your health plan(s)

Full Name of Covered Members and Dependents

Relationship Social Security Number Sex M/F Birth Date MM/DD/YY

*E

Disabled Y/N

*S

*C

*C

*C

*C

*E = Employee *S = Spouse *C = Child 4. TERMINATION OF DEPENDENTS

Name

Supporting Documentation Attached

Termination Date

Reason Code

Reason Codes 1. Divorce 2. Death 3. Child reached age limit 4. Entered military

5. Other insurance

5. MEDICARE INFORMATION (to be completed if applicable)

Are you eligible for Medicare?

Yes

No

Spouse?

Yes

No

If yes, Medicare number__________________________

If yes, Medicare number__________________________

Medicare Part A Effective Date:___________________

Medicare Part A Effective Date:___________________

Medicare Part B Effective Date:___________________

Medicare Part B Effective Date:___________________

Child?

Yes No

If yes, Medicare number__________________________

Medicare Part A Effective Date:___________________

Medicare Part B Effective Date:___________________

6. CONDITIONS OF ENROLLMENT

I hereby request coverage for myself and my eligible dependents, and authorize my employer to deduct from my earnings the amount required to participate in the elected Plans. I understand that all protected financial and health information for myself and any dependents will be gathered, shared and maintained in accordance with all applicable federal and state laws. Dependents may include my spouse and children under 26 years of age. Attainment of such age shall not terminate the coverage of a dependent child during the terms of this agreement if he or she is incapable of self-

Date

Employee Signature

sustaining employment by reason of mental retardation or physical handicap and is mainly dependent upon the subscriber for support and maintenance. Stepchildren and legally adopted children, who are in my care, are included.

I do hereby certify that I am sole support for the dependents with different last names. Enrolled dependents determined to be ineligible shall be terminated and charged for services rendered at the fee-for-service rate less any copayments and premiums paid for said dependents.

Return this form to the Department of Human Resources

CareFirst BlueCross BlueShield is the business name of CareFirst of Maryland, Inc. CareFirst BlueCross BlueShield and CareFirst BlueChoice, Inc. are independent licensees of the Blue Cross and Blue Shield Association. ? Registered trademark of the Blue Cross and Blue Shield Association. ?' Registered trademark of CareFirst of Maryland, Inc. CST4161-1N (7/18)

Notice of Nondiscrimination and Availability of Language Assistance Services

CareFirst BlueCross BlueShield, CareFirst BlueChoice, Inc. and all of their corporate affiliates (CareFirst) comply with applicable federal civil rights laws and do not discriminate on the basis of race, color, national origin, age, disability or sex. CareFirst does not exclude people or treat them differently because of race, color, national origin, age, disability or sex.

CareFirst:

Provides free aid and services to people with disabilities to communicate effectively with us, such as: Qualified sign language interpreters Written information in other formats (large print, audio, accessible electronic formats, other formats)

Provides free language services to people whose primary language is not English, such as: Qualified interpreters Information written in other languages

If you need these services, please call 855-258-6518.

If you believe CareFirst has failed to provide these services, or discriminated in another way, on the basis of race, color, national origin, age, disability or sex, you can file a grievance with our CareFirst Civil Rights Coordinator by mail, fax or email. If you need help filing a grievance, our CareFirst Civil Rights Coordinator is available to help you.

To file a grievance regarding a violation of federal civil rights, please contact the Civil Rights Coordinator as indicated below. Please do not send payments, claims issues, or other documentation to this office.

Civil Rights Coordinator, Corporate Office of Civil Rights

Mailing Address

P.O. Box 8894 Baltimore, Maryland 21224

Email Address

civilrightscoordinator@

Telephone Number Fax Number

410-528-7820 410-505-2011

You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights electronically through the Office for Civil Rights Complaint portal, available at or by mail or phone at:

U.S. Department of Health and Human Services 200 Independence Avenue, SW Room 509F, HHH Building Washington, D.C. 20201 800-368-1019, 800-537-7697 (TDD)

Complaint forms are available at .

REV. (12/17)

CareFirst BlueCross BlueShield is the shared business name of CareFirst of Maryland, Inc. and Group Hospitalization and Medical Services, Inc. CareFirst of Maryland, Inc., Group Hospitalization and Medical Services, Inc., CareFirst BlueChoice, Inc., The Dental Network and First Care, Inc. are independent licensees of the Blue Cross and Blue Shield Association. In the District of Columbia and Maryland, CareFirst MedPlus is the business name of First Care, Inc. In Virginia, CareFirst MedPlus is the business name of First Care, Inc. of Maryland (used in VA by: First Care, Inc.). ? Registered trademark of the Blue Cross and Blue Shield Association. ?' Registered trademark of CareFirst of Maryland, Inc.

Foreign Language Assistance

Attention (English): This notice contains information about your insurance coverage. It may contain key dates and you may need to take action by certain deadlines. You have the right to get this information and assistance in your language at no cost. Members should call the phone number on the back of their member identification card. All others may call 855-258-6518 and wait through the dialogue until prompted to push 0. When an agent answers, state the language you need and you will be connected to an interpreter.

(Amharic) - 855-258-6518 0

?d? Yor?b? (Yoruba) ?tt?l?ko: ?k?y?s? y?? n? ?w?f?n n?pa i ad?j?t?f? r. ? le n? ?wn d??t? p?t? o s? le n? l?ti gb? ?gb?s n? ?wn j gb?d?ke kan. O ni t l?ti gba ?w?f?n y?? ?ti ?r?nlw n? ?d? r lf. ?wn m-gb gbd pe nmb? f??n? t? w? ly?n k??d? ?d?nim wn. ?wn m?r?n le pe 855-258-6518 k? o s? d?r? n?pas ?j?r?r? t?t? a ? fi s f?n l?ti t 0. N?gb?t? aoj? kan b? d?h?n, s ?d? t? o f a ? s? so p m ?gbuf kan.

Ting Vit (Vietnamese) Ch? ?: Th?ng b?o n?y cha th?ng tin v phm vi bo him ca qu? v. Th?ng b?o c? th cha nhng ng?y quan trng v? qu? v cn h?nh ng trc mt s thi hn nht nh. Qu? v c? quyn nhn c th?ng tin n?y v? h tr bng ng?n ng ca qu? v ho?n to?n min ph?. C?c th?nh vi?n n?n gi s in thoi mt sau ca th nhn dng. Tt c nhng ngi kh?c c? th gi s 855-258-6518 v? ch ht cuc i thoi cho n khi c nhc nhn ph?m 0. Khi mt tng ?i vi?n tr li, h?y n?u r? ng?n ng qu? v cn v? qu? v s c kt ni vi mt th?ng dch vi?n.

Tagalog (Tagalog) Atensyon: Ang abisong ito ay naglalaman ng impormasyon tungkol sa nasasaklawan ng iyong insurance. Maaari itong maglaman ng mga pinakamahalagang petsa at maaaring kailangan mong gumawa ng aksyon ayon sa ilang deadline. May karapatan ka na makuha ang impormasyong ito at tulong sa iyong sariling wika nang walang gastos. Dapat tawagan ng mga Miyembro ang numero ng telepono na nasa likuran ng kanilang identification card. Ang lahat ng iba ay maaaring tumawag sa 855-258-6518 at maghintay hanggang sa dulo ng diyalogo hanggang sa diktahan na pindutin ang 0. Kapag sumagot ang ahente, sabihin ang wika na kailangan mo at ikokonekta ka sa isang interpreter.

Espa?ol (Spanish) Atenci?n: Este aviso contiene informaci?n sobre su cobertura de seguro. Es posible que incluya fechas clave y que usted tenga que realizar alguna acci?n antes de ciertas fechas l?mite. Usted tiene derecho a obtener esta informaci?n y asistencia en su idioma sin ning?n costo. Los asegurados deben llamar al n?mero de tel?fono que se encuentra al reverso de su tarjeta de identificaci?n. Todos los dem?s pueden llamar al 855-258-6518 y esperar la grabaci?n hasta que se les indique que deben presionar 0. Cuando un agente de seguros responda, indique el idioma que necesita y se le comunicar? con un int?rprete.

(Russian) ! . , . . , . 855-258-6518 , ?0?. , .

 (Hindi) :

-

855-258-6518 0

,

s -w?? (Bassa) To uu Cao! B nia k a ny e ke m gbo kpa o ni fu a-fa-tiin ny je dyi. B nia k ee we j e m ke wa m m ke nyu nyu hw we ea ke zi. m ni kpe m ke b nia k ke gbokpa-kpa m m dye e ni ii-wuu mu m ke se wii o p. Kpoo ny e m a f?n-na nia e waa I.D. kaa ein ny. Ny t sein m a na nia k: 855-258-6518, ke m m fo tee wa ke m gbo c m ke na ma 0 k dyi paain hw. ju ke ny o dyi m g juin, po wuu m m po dyi, ke ny o mu o niin ke ni wuu mu za.

(Bengali) : 855-258-6518 0

: )Urdu(

0 855-258-6518

. : )Farsi( . . . . 0 855-258-6518 .

: (Arabic) . .

. 0. 855-258-6518

.

(Traditional Chinese) 855-258-6518 0

Igbo (Igbo) Nrbama: kwa a nwere ozi gbasara mkpuchi nchekwa onwe g. nwere ike nwe bch nd d mkpa, nwere ike me ihe tupu fd bch njedebe. nwere ikike nweta ozi na enyemaka a n'ass g na akwgh gw bla. Nd otu kwesr kp akara ekwent d n'az nke kaad njirimara ha. Nd z niile nwere ike kp 855-258-6518 wee chere bb ah ruo mgbe amanyere p 0. Mgbe onye nnchite anya zara, kwuo ass chr, a ga-ejik g na onye kwa okwu.

Deutsch (German) Achtung: Diese Mitteilung enth?lt Informationen ?ber Ihren Versicherungsschutz. Sie kann wichtige Termine beinhalten, und Sie m?ssen gegebenenfalls innerhalb bestimmter Fristen reagieren. Sie haben das Recht, diese Informationen und weitere Unterst?tzung kostenlos in Ihrer Sprache zu erhalten. Als Mitglied verwenden Sie bitte die auf der R?ckseite Ihrer Karte angegebene Telefonnummer. Alle anderen Personen rufen bitte die Nummer 855-258-6518 an und warten auf die Aufforderung, die Taste 0 zu dr?cken. Geben Sie dem Mitarbeiter die gew?nschte Sprache an, damit er Sie mit einem Dolmetscher verbinden kann.

Fran?ais (French) Attention: cet avis contient des informations sur votre couverture d'assurance. Des dates importantes peuvent y figurer et il se peut que vous deviez entreprendre des d?marches avant certaines ?ch?ances. Vous avez le droit d'obtenir gratuitement ces informations et de l'aide dans votre langue. Les membres doivent appeler le num?ro de t?l?phone figurant ? l'arri?re de leur carte d'identification. Tous les autres peuvent appeler le 855-258-6518 et, apr?s avoir ?cout? le message, appuyer sur le 0 lorsqu'ils seront invit?s ? le faire. Lorsqu'un(e) employ?(e) r?pondra, indiquez la langue que vous souhaitez et vous serez mis(e) en relation avec un interpr?te.

(Korean) : . . . ID . 855-258-6518 0 . .

(Navajo)

855-258-6518

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